AAA Transport

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ALL AMERICAN AMBULANCE & TRANSPORT

EMPLOYMENT APPLICATION

ALL AMERICAN AMBULANCE & TRANSPORT gives all applicants equal consideration regardless of race, color, sex, religion, national origin, sexual orientation, marital statusor disability. The decision to hire an applicant is based on individual qualifications that meetthe job requirement.

APPLICANT INFORMATION
       
Position Desired
Hours Requested
Last Name
Date of Application

First Name
Date Available
MI
Desired Salary
Street Address    
City, State, Zip
Date of Birth
Email Address
Home Phone
Social Security #
Cell Phone
US Citizen?
Yes No
Authorized to work in US?
Yes No
   
       
EMPLOYMENT QUESTIONS
       
Have you ever been Employed at All American Ambulance and transport before?
Yes No
If Yes, List Dates
       
Do you have any friends or relatives that work at All American Ambulance and transport?
Yes No
If Yes, Who?
       
Have you ever been convicted of a crime?
Yes No
If Yes, Explain:
       
Do you have any physical, mental, or medical impairments which may limit your ability to perform job related duties?
Yes No
If Yes, Explain:
 
How did you hear about AAA Transport?
       
CERTIFICATIONS / LICENSES
       

Currently an NREMT?

Yes No

PSC License?

Yes No

Do you have EVOC?

Yes No

CDL License?

Yes No
       

Have you ever driven an emergency vehicle?

Yes No

If so, where?

       

Highest level of Medical Certification: 1st Responder EMT-Basic EMT-Intermediate EMT-Paramedic None

       
Certifications   State Certification Number
       
Driver's License # State Issued
Do you have points on your driving record? Yes No If so, how many?
 
EDUCATION
       
High School attended
Location (City/State)
Did you graduate or receive a GED?
Date graduated, or received GED
       
College or University Location (City/State) Dates attended Major or Degree awarded
       
PERSONAL REFERENCES
       
REFERENCE 1
Full Name Occupation Address City, State, Zip
Relationship Home Phone Cell Phone Email
REFERENCE 2
Full Name Occupation Address City, State, Zip
Relationship Home Phone Cell Phone Email
REFERENCE 3
Full Name Occupation Address City, State, Zip
Relationship Home Phone Cell Phone Email
       
EMPLOYMENT HISTORY
       
EMPLOYER 1
Company Address Supervisor Phone Number
Job Title Salary Dates Employed Reason for Leaving
EMPLOYER 2
Company Address Supervisor Phone Number
Job Title Salary Dates Employed Reason for Leaving
EMPLOYER 3
Company Address Supervisor Phone Number
Job Title Salary Dates Employed Reason for Leaving
       
VOLUNTARY DISCLOSURE
       

OUR COMPANY CONSIDERS QUALIFIED APPLICANTS FOR EMPLOYMENT WITHOUT REGARD TO RACE, COLOR, RELIGION, NATIONAL ORIGIN OR ANCESTRY, DISABILITY, GENETIC INFORMATION, GENDER, AGE, SEXUAL ORIENTATION, COVERED VETERANS STATUS, OR ANY OTHER PROTECTED STATUS. AS AN EQUAL OPPORTUNITY EMPLOYER AND A FEDERAL CONTRACTOR, VARIOUS GOVERNMENT AGENCIES, (THE U.S. DEPT. OF LABOR) REQUIRE US TO REPORT CERTAIN DATA ABOUT APPLICANTS AND MAINTAIN AN AFFIRMATIVE ACTION PLAN. WE MUST TRY TO OBTAIN ACCURATE INFORMATION ABOUT RACE/ETHNIC GROUP AND SEX/GENDER FOR ALL APPLICANTS. THE INFORMATION OBTAINED MAY ONLY BE USED IN ACCORDANCE WITH THE PROVISIONS OF APPLICABLE LAWS, EXECUTIVE ORDERS, AND REGULATIONS, INCLUDING THOSE THAT REQUIRE THE INFORMATION TO BE SUMMARIZED AND REPORTED TO THE FEDERAL GOVERNMENT FOR CIVIL RIGHTS ENFORCEMENT. WHEN REPORTED, DATA WILL NOT IDENTIFY ANY SPECIFIC INDIVIDUAL. THE INFORMATION COLLECTED ON THIS FORM IS MAINTAINED IN A SECURE AND CONFIDENTIAL MANNER AND IS NOT COMMUNICATED TO PERSONS MAKING HIRING OR OTHER EMPLOYMENT DECISIONS. WHILE YOUR REPLY WILL BE MOST HELPFUL TO USE IN REPORTING ACCURATE DATA, DISCLOSURE IS COMPLETELY VOLUNTARY. CHOOSING NOT TO PROVIDE THIS INFORMATION WILL NOT LEAD TO ANY ADVERSE TREATMENT. BY COMPLETING THIS FORM, YOU ARE VERIFYING THAT YOUR INFORMATION IS ACCURATE AND THAT YOU UNDERSTAND THIS INFORMATION WILL BE KEPT CONFIDENTIAL; DISCLOSURE OF THIS INFORMATION DOES NOT IN ANY WAY EFFECT WHETHER OR NOT YOUR APPLICATION RECEIVES CONSIDERATION; AND THE SOLE USE OF THIS INFORMATION IS FOR INCLUSION IN STATISTICAL REPORTS REQUIRED BY VARIOUS US GOVERNMENTAL REGULATIONS AND AGENCIES.

   
Accept Voluntary Disclosure      Decline Voluntary Disclosure
   

Please indicate sex and ethnic background by checking the appropriate boxes below

You only have to answer questions below if you have choosen to accept voluntary disclosure
Male
Female
   
American Indian or Alaskan Native - a person having origins in any of the original peoples of North America and South America (including Central America), and who maintains tribal affiliation or community attachment.
Asian - a person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.
Black or African American - a person having origins in any of the Black racial groups of Africa. Terms such as Haitian or Negro can be used in addition to Black or African American.
Native Hawaiian or Other Pacific Islander - a person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.
White - a person having origins in any of the original peoples of Europe, North Africa, or the Middle East.
Hispanic or Latino - a person of Mexican, Puerto Rican, Cuban, Central or Southern American or other Spanish culture or origin, regardless of race.
Hispanic or Latino (White race only) - a person of Mexican, Puerto Rican, Cuban, Central or Southern American or other Spanish culture or origin of the White race.
Hispanic or Latino (all other races) - a person of Mexican, Puerto Rican, Cuban, Central or Southern American or other Spanish culture or origin of any race other than White.


ACKNOWLEDGEMENT
 

I certify that all information given in this application is correct and complete to the best of my knowledge and I further understand and agree that my misrepresentations, falsification, or willful omission of facts therein shall be sufficient cause for my immediate dismissal after hire or refusal of employment. I understand that acceptance and offer of employment does not create a contractual obligation to continue to employ me in the future. Permission is hereby granted to solicit and investigate statements from any person or organization with regard to my personal history and prior employment.

I Agree All Statements are Truthful
 

All American Ambulance & Transport is a drug and alcohol free workplace. At anytime during our pre-employment process and/or while employed, you may be given a drug and alcohol screening test. If you do not pass the screening test, you will no longer be considered for employment or could be dismissed from All American Ambulance & Transport. I have read and understand this requirement.

I Agree to Drug and Alcohol Policy
       

I voluntarily give All American Ambulance & Transport permission to make a thorough investigation of my personal, criminal, educational background, past employment history and all facts within my application and release from liability and/or responsibility all persons, places, businesses, and municipalities supplying such information.

I Agree to Background Investigation
 
***YOU MUST AGREE TO ALL ABOVE STATEMENTS FOR THIS APPLICATION TO BE PROCESSED***
Please type your signature here:  
Who may we thank for referring you?  
For security protection, please provide the SUM for the mathematical equation:
 


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Lothian, MD 20711

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